Ann Patchett - State of Wonder

Dr. Swenson shook her head. “That takes forever, causes a great deal of pain, and half the time it doesn’t work anyway. We’ll do a section.”

Marina removed her hand from the woman. “What do you mean it takes forever? Where do we have to go?”

From her perch on the wooden box Dr. Swenson dismissed the suggestion out of hand. “There’s no point in putting her through all of that if in the end you’ll have to do the section anyway.”

Marina sat back on her heels. “The point is we don’t have anything approaching sterile conditions. The chance of her dying from a postoperative infection is enough to indicate that turning the baby is worth a try. I don’t have a nurse to help me with a surgery, I don’t have an anesthesiologist.”

“Do you think we keep an anesthesiologist around here?”

“What do you have?” Marina pulled off a glove and poked through the bag.

“Ketamine. And don’t go throwing gloves away. This isn’t Johns Hopkins.”

“Ketamine? Are we planning on sending her out to a disco later? Who in the world uses Ketamine?”

“Here’s the news, Dr. Singh, you get what you get, and I was lucky to get that.”

“I’m going to try and turn the baby,” Marina said.

“You’re not,” Dr. Swenson said. “It is enough that I had to go up that godforsaken ladder. I would appreciate it if you did not make me get down on the floor as well. Even if it were possible to take my leg out of the equation, I have edema in my hands.” Dr. Swenson held up her hands for exhibition. Her fingers were swollen out straight and the skin was pulled tight. Ten little sausages.

“Dear God, when did that happen?” Marina reached up for a hand and Dr. Swenson jerked it away.

“I would have a difficult time with the scalpel. I have a difficult time with a pencil. All that said, either you are going to do the cesarean or I am. Those are the choices.”

“What is your blood pressure?” Marina asked.

“I am not your patient,” Dr. Swenson said. “You would do well to keep your attention on what is in front of you.”

The man in the gray T-shirt looked from Dr. Swenson to Dr. Singh, holding his wife’s hand. Clearly, their disagreement concerned him. It did not concern his wife, who took the opportunity to close her eyes for the two minutes she had between contractions. Had someone asked Marina whose opinion was more valuable on the question of whether or not to proceed with a cesarean — the former head of obstetrics and gynecological surgery at Johns Hopkins who had not touched the patient, or the obstetrics and gynecological surgery dropout who was touching her first patient in thirteen years — Marina would cast her lot with the former. Still, being the latter, she was sure she was right, and equally sure she wasn’t about to physically prevent her mentor from taking over the case. That left her one option. “Tell me how to use the Ketamine,” she said.

The Ketamine was put in a syringe, which, once the needle had been inserted into the vein, was taped to the inner arm so that it could be slowly tapped in as needed, and with that tapping the patient ceased to whimper. Marina washed and dried the woman’s belly, straightened out her legs, and, putting on clean gloves, showed her nurse how to hold the skin taut. She had her nurse’s attention now. The woman was wide-eyed and still while Marina slid the scalpel into the skin. Once she felt the knife insert, it occurred to her that this was not her first surgery after so many years. It wasn’t a week ago she had cut through the snake. The subcutaneous fat welled up through the line of the incision like clotted cream dotted with the first bright beads of blood.

That cut, which passed without a sound save a small gasp from the husband, drew the sudden attention of everyone in the hut. Even the old man pulled himself out of the hammock and brought the two children over to see. The other two women, and the man with the knife, all gathered round for the show, leaning forward and pushing a little to get the best view. Marina felt someone’s knees against her back. “This isn’t helping,” she said.

Her nurse, hands steady on either side of the incision, barked out an order, and the circle immediately took one big step back.

“Now we’re looking for the fascia,” Dr. Swenson said. “I didn’t bring my glasses. Do you see it there, under the fat?”

“I’ve got it,” Marina said. She took the nurse’s hands and put a shoehorn in each one. She dug the horns into the incision and showed the woman how to pull. There was the uterus. Despite the drowning flood of adrenaline she recognized it all — bowel and bladder, it was perfectly familiar. Why was that so surprising? She had given up her profession, not her knowledge. Marina, half blinded by her own sweat, turned her face to Dr. Swenson who picked a shirt up off the floor and wiped her down. Dr. Swenson then leaned forward and blotted off the face of the nurse, who was wrestling mightily to keep the cavity open wide with her shoehorns.

“Now take the bladder down,” Dr. Swenson said. “Don’t nick it. You see the bladder, don’t you?”

“I do,” Marina said. It was a miracle to see anything without direct light. She cut into the uterus carefully, avoiding everything that was not meant to be cut, and the blood boiled up into the cistern of the belly. Blood, combined with the great slosh of amniotic fluid, made a dark and raging ocean Marina could not get past. The hot liquid broke over the floor and pooled beneath the doctor and her patient. “How in the hell do you do this without suction?”

“There’s a bulb in the bag,” Dr. Swenson said.

“I need another set of hands.”

“You don’t have them. Make do.”

Marina grabbed at the bulb which shot out of her bloody glove and skidded across the floor where it was caught, like all balls, by a five-year-old boy loitering nearby. “Christ!” Marina said. “At least get somebody to wash it off.”

And Dr. Swenson, without a word, motioned for the bulb to be run through the bucket with soap and water and so it was returned to Marina who used it to pull up a half pint of liquid that she then shot onto the floor beside her. She did it again. There, beneath so many layers, she could see the baby face down, feet to the head, bottom lodged firmly in the pelvis. Marina tried to sit the baby up but it was stuck.

“Lift the breech,” Dr. Swenson said.

“I’m trying,” Marina said, irritated.

“Just tug it up.”

Marina moved the shoehorns to the inside of the uterus and motioned for the nurse to pull, to really pull, which this woman who was herself doomed to a lifetime of constant reproduction did with all her might while Marina reached in and tried to pry the baby out. It was wedged into the mother like a child who had shoved himself into the tiniest cabinet during a childish game and could then not be coaxed out. The muscles in Marina’s shoulders and neck strained, her back pulled. It was a physical test of strength, 142 pounds of Marina Singh against six pounds of baby, and then with a great sucking sound the baby dislodged. The man with the knife put his hand on Marina’s back to keep her from falling over. Red and white and shining, one entire boy flipped over on the mother’s chest.

“Look at that. Could that have been easier?” Dr. Swenson gave a single, decisive clap. “Give the baby to them now. They know all about this.” No sooner were the words spoken than the slippery child was out of her hands, the thick liver of placenta going with him. The entire crowd bore him away, the old and the young made off with the astonishingly new. They had proof of something spectacular happening now. As many births as there had been no one was completely inured to the charms of infants. “Do you remember the rest of it? Massage the uterus now. This is the part I always liked, reconstruction, restoring order to the chaos.” Dr. Swenson leaned forward for a better look. “The baby is gone, he’s someone else’s problem, and you can pay more attention to the details. There isn’t the same sense of urgency.”